RCPA - Rehabilitation and Community Providers Association


Medicare Passive Enrollment Lawsuit Proceeds
January 24, 2006

The Pennsylvania Health Law Project (PHLP) has requested assistance locating consumers and providers who have had problems with the passive enrollment of dual eligible individuals into a Medicare health maintenance organization (HMO), a Medicare Advantage Plan. Consumers and providers are needed to serve as witnesses for a class action lawsuit filed on behalf of Pennsylvania dual eligibles who were passively enrolled into a Medicare Advantage plan from original Medicare or the Medicare plan that they had affirmatively chosen.

Transition plans are in effect so that individuals can access medications previously received under Medicaid HMOs and have access to any Medicare provider, regardless of plan network status. However, these plans are not working well and people are not getting the needed medications or care, often because they are not aware of the plans. PHLP tried to reach a settlement with the Centers for Medicare and Medicaid Services (CMS) that would require them to educate consumers and providers and establish a system to facilitate disenrollment for consumers. According to PHLP, CMS has discontinued settlement discussions on these issues and the lawsuit will proceed.

Consumers are needed who:

  • Were denied medications received under Medicaid HMOs or had great difficulty obtaining them;
  • Were unable to see a provider not in the Medicare HMO network;
  • Were unable to see a specialist or receive other care because they did not have a referral or authorization by the plan; and
  • Are receiving what they need during the transition period, but will be at risk due to network or formulary issues on April 1 when the transition period ends.

Medicare providers are needed who:

  • Do not know about transition plans;
  • Are unable to use the transition plan due to lack of information on billing, plan refusal to pay, or onerous prior authorization or other processes;
  • Are unable to arrange services for dual eligibles due to passive enrollment; and
  • Have had problems or delays in efforts to join and participate in plan networks.

Other providers are needed who have been unable to organize and coordinate care for passively enrolled dual eligibles or have been unable to obtain information about transition plans or coverage that will occur after April 1.

Those who meet the criteria and are willing to serve as witnesses should complete the PHLP questionnaire. Although the questionnaire is focused on the individual, providers should complete pertinent information and provide additional information on a separate page. Return the completed questionnaire to Alissa Halperin, managing attorney, PA Health Law Project (ahalperin@phlp.org or 215-625-3879 [Fax]). Direct questions to Betty Simmonds or Linda Drummond at PCPA.

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